Title: The Drug Treatment System and its key transitions. Three Current Approaches and how to Integrate Them
1The Drug Treatment System and its key
transitions.Three Current Approaches and how to
Integrate Them
- UKDWF Conference 2009
- Ian Wardle
- October 2009
2Introduction
- Joining up the individual and the social
3The Individual AND the Social
- Medical training can be faulted by social
science for its centering on the care of
individuals, for individualizing the issues which
are properly social and should be taken at the
population level. - Along both those tracks, Robin Room was a friend
who would check me if I ever lapsed too much into
a narrowly patient-centred view. The richest
insights come and the best policies evolve when
one sees and honours the realities of the
individual, but at the same time grasps the
realities of the population - Griffith Edwards, Interview in Addiction, 1990
4Context 3Joining-up National Policy
- Outline of Government Targets
- One of the difficulties of establishing national
outcomes measures arises from the fact that each
government department has its own aims and
objectives, for example -
- Ministry of Justice To protect the public and
reduce re-offending - Department of Health Improve the health and
well-being of people in England - Home Office Reduce the harm that drugs cause to
society, to communities, individuals and their
families.Outcomes Paper PDTSRG, September 2009
5Three Key Approaches
- The Language of Care
- Therapeutic Change Paradigms
- The Language of Integration and Complexity
- Systems Paradigms
- The Language of the Mainstream
- Adaptation, Incorporation and Improvement and
Retrenchment
6Two different kinds of challenge
- Therapeutic Change paradigms challenge the
dominant philosophies and models of care. - Systems theorists and practitioners challenge the
ruling paradigms of management and government.
7Systems Paradigms
- Contextualist
- Multiple sub-systems
- Complexity
- Suitable for Messes
- System-mapping focus with emphasis on populations
- Concern isolation of strategy
- Critical of gaps in knowledge, historical
forgetting and lack of integration and
innovation and efficiency
- Linear and Reductionist
- Single system approach
- Simplicity
- Suitable for difficult problems
- Milieu focus with emphasis on individual
- Concern direction of strategy
- Critical of evidence base and mainstream expert
driven knowledge production
8Critiques of the Status Quo 1
- Therapeutic Change Approaches
9Therapeutic Change Paradigms 1
- William White is a thinker stressing therapeutic
paradigm change. In his paper, Addiction
recovery Its definition and conceptual
boundaries (2007), he describes us as being "on
the brink of shifting from long-standing
pathology and intervention paradigms to a
solution-focused recovery paradigm"
10Therapeutic Change Paradigms 2
- In Fragmented Intimacy, Peter Adams describes how
the medical profession, and more latterly, the
profession of psychology have, over the course of
the past century, defined and dominated orthodox
drug treatment. - For Adams, we need to move beyond what he calls
the particle paradigm, with its biopsychosocial
underpinnings, towards a social paradigm "which
shifts the focus of attention away from people as
discrete individuals and towards people in terms
of their relationships.
11Therapeutic Change CritiquesCommon Features
that interweave this growing body of work
- A criticism of the dominant roles of
professionals, particularly in medicine and
psychology - An understanding that those who suffer from
addiction must play a greater role in their own
recovery - A growing awareness that addiction can best be
understood as a social concept and not as
something solely about the pathologies of
individuals and, finally - An understanding that addiction is a phenomenon
that is best tackled at the level of the
communities in which it is found. -
12Critiques of the Status Quo 2 --Systems Change
and Complexity
- Systems Thinking and LSPs
- Systems Thinking in Organisations
- Systems Thinking in National Policy
131(a). Systems Thinking and LSPs
- Complexity stares you in the face when
confronting wicked issues with multiple
stakeholders, which is what Local Strategic
Partnerships do. - The growing complexity involved in this governed
interdependence is challenging the performance
management systems that have become such an
established feature of public policy in the UK
and worldwide. - Making performance management work in these
circumstances is a current frontier of policy
development.
141(b) Systems Thinking and LSPs
- Places matter because they are open, dynamic and
adaptive systems that do not have a simple
cause-effect relationship with national or global
drivers of economic, social or policy - They are a setting for intervention, but with
outcomes more likely to arise from complex causal
combinations than linear cause and effect. - Tim Blackman--Placing Health Neighbourhood
renewal, health improvement and complexity, 2006,
152. Systems Thinking in Organisations
- The fact is that public-service workers have
been 'cheating' their systems to meet their
targets, a practice which has become known in the
NHS as 'gaming' -- a new word for the management
lexicon, a word of our time. - It is a consequence of the quasi-market. The
regime administering this madness is called
'payment by results'. It is a misnomer it should
be called 'payment for activity'. - What was supposed to be a system for liberating
public-sector organisations has turned into a
burgeoning and dysfunctional stranglehold of
bureaucratic control. - John Seddon, Systems Thinking in the Public
Sector, 2008
163. Systems Thinking in National Policy, Scotland
17Centralism or Localism? Or a mixture of both?
- Key questions for the drug treatment field in
2010.
18Question Should we aim to go from (A) to (B) or
seek to integrate the best of both
- (A) CENTRALISED, EXPERT, MODEL
- (B) LOCALLY LED, RECOVERY MODEL
- The new local, systems-based Recovery
therapeutics aim to enable a more accessible,
person-centred, community-embedded and
qualitative social therapeutics of need
- The current, silo-based, centralised,
target-driven expert led, evidence-based
therapeutics sit within a strategic framework of
population-level risk management
19Three sets of Questions
- Can we go from a predominantly stabilising and
palliative model of care to a recovery-based
model - Can we go from a silo-based, command and control
model to a local soft-systems approach where
partners share learning and performance
objectives - Can we go from a national system of directional
leadership to regional, sub regional and local
systems characterised by partnership,
personalisation and community embeddedness.
20We are being asked to make three sets of
transitions as part of a single transitional
process
- Three transitions
- From Centrally Driven to Locally Owned
- From Expert-Led to Person-Centred
- From Silo-Based to Systems Based
-
(A) Centrally Driven
(B) Locally Owned
Systems-Based/Complex
Recovery/Person- Centred
Palliative/ Expert-Led
Silo-Based/ Simple
21(A) Existing Professional And Medicalised Therapeutics Sit within a Paradigm of Population Level Risk Management (B) The New Therapeutics aim To Enable a Broader Person-Centred, User-Led, Community-Based Social Therapeutics of Need
Corporatist Organisations fed by government Sovereign, Independent Institutions
Centralist Devolved and Localised
Medicalised and individualised (biopsychosocial) interventions A broader, social understanding of addiction
Commissioned by local agents against national targets Commissioned against sustainable local criteria
Stakeholder and Expert led Beneficiary and Public led
Service users endorse system Service users drive system
Detached (professional) Embedded (community)
Evidence Based and Best Practice Experiment and Innovation
Compartmentalised according to department, profession and agency. Partnership and joint planning
Standards driven up by competition Standards driven up by shared learning
22Key points arising from devolution to local,
regional and sub-regional structures.
- Our industry has grown strong under precisely
Centralised, Command and Control system that John
Seddon criticises - The LSP, devolution, revolution will not
necessarily chose those national indicators that
prioritise, either directly or indirectly, drug
treatment - Post pooled treatment budget, local priorities
will shift, the more so since local elections and
other forms of local democracy may well result in
less being spent on drug treatment - National targets, however onerous and, it may be
argued, mis-placed, have at least come with
National Priorities and Central Investment.
23Key points arising from devolution to local,
regional and sub-regional structures.
- Drug treatment its scale, its philosophical
underpinnings, its models of care and its ranking
as a funding priority are not immune from the
party political cycle. - Our own industry debates are susceptible to
political appropriation. - At all times we must be capable, as a field, of
speaking powerfully, positively and clearly to
the public about the full range of social
benefits associated with accessible and effective
drug treatment. - Improved health for patients and public, lower
rates of drug-related offending and re-offending
and safer communities.
24Key points arising from devolution to local,
regional and sub-regional structures.
- Any politicians that insist upon taking a step
back and reversing the progress we have made as a
field, must not then be able to claim that they
werent clearly warned about the consequences of
disinvestment from treatment or from taking
ill-informed and politically-motivated changes of
direction.